Citation Nr: 1337133 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 09-18 888 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUES 1. Entitlement to service connection for a psychiatric disorder, to include depression and obsessive compulsive disorder. 2. Entitlement to service connection for a left wrist disorder. 3. Entitlement to service connection for hearing loss. 4. Entitlement to service connection for the residuals of shin splints. 5. Entitlement to service connection for left elbow strain. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The appellant served in the US Army Reserves from June 1988 to August 1988 and from June 1989 to July 1989. He also served on active duty in the US Army from June 1991 to May 2003, and from May 2003 to June 2007. The character of service for his last period of active service from May 2003 to June 2007, was dishonorable. Consequently, the period of dishonorable service from May 2003 to June 2007 is a bar to VA benefits; however, the Board will still consider the Veteran's claims in regard to his honorable periods of service. This case comes before the Board of Veterans' Appeals (Board) on appeal of a May 2008 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, which in pertinent part, denied the benefits sought on appeal. In October 2009 the Veteran provided testimony before the undersigned Veterans Law Judge. A transcript of that hearing is in the claims folder. The appeal was previously remanded by the Board in April 2010 and November 2012, for additional development. That development having been completed, the case has been returned to the Board at this time for further appellate review. The Veteran's claims of service connection for an upper gastrointestinal disorder, the residuals of rope burn to the right hand, acne, plantar fasciitis, heel spurs, Achilles tendonitis of the right foot, a left knee disorder, and degenerative joint disease and hallux valgus of the right great toe, were also previously before the Board in April 2010 and November 2012 when they were remanded for additional evidentiary development. The claims were granted by subsequent rating action in May 2013 and June 2013. Therefore, these issues have been resolved and are not on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (because appellant's first appeal concerned rejection of logically up-stream element of service connection, appeal could not concern logically down-stream elements), and Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). As a final preliminary matter, the Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with this appeal. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. An application to reopen the claim of entitlement to service connection for tinnitus has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to service connection for left elbow strain addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. A chronic psychiatric disorder was not shown during the Veteran's period of honorable service, and the most probative evidence indicates that the Veteran does not suffer from obsessive compulsive disorder and that his depressive disorder is not shown to have had onset during service or to be etiologically related to any injury, disease, or event of service origin. 2. A chronic left wrist disorder was not shown during the Veteran's period of honorable service, and his current left wrist condition, diagnosed as left wrist carpal tunnel syndrome, is not shown to have had onset during service or to be etiologically related to any injury, disease, or event of service origin. 3. The most probative evidence of record indicates that a hearing loss disability for VA compensation purposes has not been shown at any time during the appeal. 4. The most probative evidence of record indicates that residuals of shin splints have not been shown at any time during the appeal. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a psychiatric disorder, to include depression and obsessive compulsive disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). 2. The criteria for establishing service connection for a left wrist disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). 3. The criteria for establishing service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.385, 4.85, 4.86 (2013). 4. The criteria for establishing service connection for residuals of shin splints have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent in May 2013. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letter also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disabilities under consideration, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice was timely because the claims were readjudicated in the June 2013 supplemental statements of the case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran appeared at a hearing before the Board. He presented oral testimony in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the hearing, the Veterans Law Judge noted that basis of the prior determination, asked specific questions directed at identifying the elements of the claims that were lacking to substantiate the claims for benefits, and elicited testimony from the appellant in regard to his service during the period in question. In addition, the Veterans Law Judge sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). By contrast, the hearings focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issue has been obtained. The Veteran's service treatment records, the Virtual VA file, and available private and VA treatment records have been obtained. In addition, he has been provided with appropriate VA examinations in connection with the claims herein decided, which provide etiological opinions and sufficiently describe the manifestations of the Veteran's disabilities for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Moreover, the Veteran has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b) (2013). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a Veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and a chronic disorder becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2002). In order to rebut the presumption of soundness at service entry, there must be clear and unmistakable evidence showing that the disorder pre-existed service and there must be clear and unmistakable evidence that the disorder was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). As noted in the Introduction of this decision, the character of service for the Veteran's last period of active service from May 2003 to June 2007, was dishonorable. Consequently, the period of dishonorable service from May 2003 to June 2007 is a bar to VA benefits. See 38 C.F.R. § 3.12 (2013); Cropper v. Brown, 6 Vet. App. 450, 452 (1994). The Board will still consider the Veteran's claims in regard to his honorable periods of service. Psychiatric Disorder The Veteran contends that he is entitled to service connection for a depression with obsessive compulsive disorder (OCD). The service treatment records show that at the time of enlistment in service in April 1991, the Veteran related a pre-service history of depression at age 17 due to girl problems. He denied treatment with medication or any subsequent recurrence. On examination, no psychiatric pathology was noted. Thereafter, in October 2002 the Veteran was seen for complaints of knee problems and a diagnosis of OCD was noted. In August 2002, it was noted that a psychiatrist had diagnosed OCD treated with prescription medication, although records upon which the diagnosis was based were determined to be unavailable. The Veteran was psychiatrically evaluated in July 2004. He was diagnosed with major depressive disorder, recurrent, well controlled with medication. The identified stressor was the Veteran's confinement. Subsequent service treatment notes show continued treatment for depression. The Veteran underwent a mental health disorders examination in April 2013. The examiner diagnosed depressive disorder not otherwise specified. The examiner opined that the Veteran's depressive disorder predated military service based on the Veteran's reported history of an episode of depression with suicidal ideation in high school, prior to service. The examiner opined that the Veteran's depressive disorder was not aggravated by service beyond the natural progression of the condition. Identified environmental and psychosocial stressors were family related. The examiner further noted that an August 2002 service treatment record contained a diagnosis of OCD by a previous medical provider, a psychiatrist, and the report noted "no records." Based on a review of the evidence of record, the examiner found that there was no persuasive basis for a diagnosis of OCD at any time, and on examination the Veteran did not meet the criteria for a diagnosis of OCD. In this regard the examiner explained that a diagnosis of OCD required either obsessions or compulsions, which were not evident on examination. While the Veteran reported counting cars while driving when he was in service, the examiner determined that this behavior did not qualify as compulsion for a diagnosis of OCD as it did not cause marked distress, was not time consuming and did not interfere with functioning. Similarly, the Veteran's report of collecting memorabilia, which he bought and sold over the internet as a business, did not qualify as compulsive behavior for purposes of a diagnosis of OCD. Moreover, the Veteran denied engaging in either behavior anymore. Initially, the Board notes that at the time of enlistment, in April 1991, the Veteran related a pre-service history of depression at age 17, but no psychiatric pathology was noted on examination on service enlistment. The Board notes that a history provided by the Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). In this case, the presumption of soundness applies because the Veteran's entrance examination found him to be psychiatrically normal. Moreover, the presumption of soundness has not been rebutted by clear and unmistakable evidence. In this regard, there is insufficient evidence establishing that a psychiatric disorder clearly and unmistakably existed prior to service. The only evidence suggesting that there may have been a pre-existing disorder is the Veteran's own reported history at the time of his service entrance examination and on VA examination in April 2013, which does not amount to clear and unmistakable evidence, particularly in light of the psychiatric examination findings in April 1991. Thus, it cannot be said that there is clear and unmistakable evidence showing that he had a preexisting psychiatric disorder. Accordingly, the presumption of soundness is not rebutted. Therefore, the Board's analysis must turn to the issue of whether depression and OCD were incurred during the Veteran's active service. Wagner, supra. The Board recognizes the service treatment records documented a diagnosis of OCD during the Veteran's period of honorable service. The diagnosis is considered competent evidence as it was rendered by medical professionals. Nonetheless, the in-service diagnosis of OCD appears to have been based solely on history provided by the Veteran as the absence of records in support of such diagnosis was noted at that time. Moreover, the diagnosis of OCD was not supported by any rationale and, as a result, the in-service treatment records that reflect a diagnosis of OCD, are considered less probative. The Board further finds that other independent medical evidence is against the claim. In this regard, the VA examiner in April 2013, noted that while service treatment records in 2002 documented a diagnosis of OCD there was no evidence at that time to support such diagnosis, or at any time thereafter. This opinion was rendered following claims file review and examination of the Veteran. It also was based on consideration of the Veteran's reported history and specific criteria for a diagnosis of OCD. The opinion also was based on a medically articulated rationale. As such, this opinion is entitled to great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Significantly, there is no other evidence of record to showing a diagnosis of OCD at any time during the appeal. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110 (West 2002); see Degmetich v. Brown, 104 F.3d 1328 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). In the absence of probative medical evidence showing that the Veteran currently has OCD, the probative and persuasive evidence weighs against the Veteran's claim. The Board is cognizant of the Veteran's contentions that he currently has OCD. While he is competent to report his symptoms, there is there is no indication that he has any specialized training in diagnosing psychiatric disorders or determining their etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, there are numerous psychiatric disorders with numerous potential etiologists; thus, determining the diagnosis and etiology of mental health symptoms requires medical expertise. Accordingly, the Veteran's opinion that he has OCD is not competent medical evidence. The Board accords significantly greater weight to the opinion of the VA examiner than to the Veteran's lay assertions. With regard to service connection for a psychiatric disorder other than OCD, the Veteran's service treatment records for his period of service through May 2003, do not show any psychiatric condition, to include depression. The Veteran was initially treated for a depressive disorder in July 2004 while incarcerated, and there is no evidence of psychoses during service or within one year following the Veteran's honorable period of service. 38 U.S.C.A. § 1112 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). None of the Veteran's medical providers have related a psychiatric disorder to any aspect of his military service. The Veteran's depressive disorder has been associated with situational stressors. Specifically, in July 2004 his depressive disorder was associated with his confinement. Thereafter the VA examiner in April 2013, diagnosed depressive disorder not otherwise specified and identified environmental and psychosocial stressors that were family related, specifically, children with special needs. There is no competent medical opinion to the contrary. To the extent the Veteran alleges he suffered from depression during service and since service such allegation is contrary to his report on the service treatment records through May 2003, such contention, being rendered in connection with his current claim, is not credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006) (the lack of contemporaneous medical records, the significant time delay between the affiants' observations and the date on which the statements were written, and conflicting statements of the Veteran are factors that the Board can consider and weigh against a Veteran's lay evidence); see Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a Veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). In summary, the most probative evidence of record indicates that the Veteran was not shown to have a psychiatric disability during service or for many years thereafter. Moreover, the most probative evidence indicates he does not meet the diagnostic criteria for OCD, and that his currently diagnosed depressive disorder is related to current situational factors, not service. Accordingly, the probative and persuasive evidence is against the claim for service connection for depression and OCD. The claim is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Left Wrist The Veteran contends that he is entitled to service connection for a left wrist disorder. At the October 2009 hearing he testified that he developed left wrist symptoms during service, associated with repeated heavy lifting in the artillery field. The service treatment records document complaints of left wrist pain associated with lifting, and treatment for left wrist tendonitis, to include use of a splint, in December 1994 and January 1995. The Veteran underwent a joints examination in February 2002. He reported a history of onset of symptoms associated with the left wrist in 1994. The Veteran denied any left wrist symptoms at the time of the examination. On examination, the examiner noted tenderness in the mid dorsum of the hand. The examiner diagnosed left wrist strain disorder pending x-rays, which were subsequently found to be essentially normal. On general medical examination in February 2002, the Veteran related a history of left wrist tendonitis associated with repeated lifting. Left wrist pain and discomfort went away once the Veteran stopped engaging in repetitive lifting motions. The examiner diagnosed a history of left wrist tendonitis, resolved. A report of medical history in January 2003 noted the Veteran's report of tendonitis in the wrists associated with lifting artillery rounds in 1994. The Veteran also reported occasional tingling in the arms and hands. On VA examination in April 2013, the Veteran reported treatment for left wrist tendonitis in December 1994. He also related onset of left hand/finger numbness in 1996, when typing. The Veteran endorsed current periodic episodes of left hand/finger numbness triggered by certain activities. The symptoms were more common during the Veteran's employment from 2005 to 2012, which involved a great deal of repetitive movements with both wrists. The examiner indicated that examination of the left wrist was consistent with carpal tunnel syndrome. The examiner noted a diagnosis of left wrist tendonitis in December 1994 and a diagnosis of left wrist carpal tunnel syndrome in 2013. The examiner opined that the Veteran's 1994 diagnosis of tendonitis was based on the Veteran's report of left wrist pain, which he currently denied. As such, a diagnosis of left wrist tendonitis was no longer appropriate, rather, examination findings were consistent with left wrist carpal tunnel syndrome, which was not shown in service and which was most symptomatic during the Veteran's employment from 2005 to 2012. As such, the examiner concluded that it was less likely than not that the Veteran's current left wrist disability was incurred in service, or was secondary or aggravated by any service-connected disability. The Board recognizes that the service treatment records documented a diagnosis and treatment for left wrist tendonitis in 1994 and 1995. The records further show that the Veteran continued to report a history of left wrist tendonitis, however, the remainder of the service treatment records contain no additional findings consistent with a chronic left wrist disability, to include tendonitis. As such, the service treatment records lack the combination of manifestations sufficient to identify a chronic left wrist condition as distinguished from merely isolated findings. Rather, the record suggests that the in-service 1994 and 1995 left wrist tendonitis associated with repeated heavy lifting in the artillery field resolved with treatment. See 2002 and 2013 examination reports. Additionally, to the extent that left wrist tendonitis was noted in service, the VA examiner in April 2013 specifically found that the Veteran's 1994 diagnosis of tendonitis was based on the Veteran's report of left wrist pain, which he denied at the time of the examination, and as such, a diagnosis of left wrist tendonitis was no longer appropriate. The examiner attributed the Veteran's left wrist disorder, carpal tunnel syndrome, to his post service employment. This opinion was rendered following claims file review and examination of the Veteran. It also considered the Veteran's service treatment records, and included a rationale for the conclusion reached. This opinion is entitled to great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Significantly, there is no other evidence of record to showing a diagnosis of left wrist tendonitis at any time during the appeal. To the extent that the Veteran alleges that he currently has left wrist tendonitis which is related to service, the probative evidence of record fails to show current disability in this regard. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110 (West 2002); see Degmetich v. Brown, 104 F.3d 1328 (1997). The probative and persuasive evidence is against a finding that the Veteran currently has tendonitis for which service connection may be granted. With regard to service connection for a left wrist disorder other than tendonitis, on VA examination in April 2013, the examiner indicated that the left wrist findings were consistent with carpal tunnel syndrome. The service treatment records do not document left wrist carpal tunnel syndrome. The evidence shows that while in a report of medical history in January 2003, the Veteran reported occasional tingling in the arms and hands he was initially diagnosed with left wrist carpal tunnel syndrome approximately 10 years after discharge from service. None of the Veteran's medical providers have related left wrist carpal tunnel syndrome to any aspect of his military service. Rather, the only competent medical opinion of record opposes the claim. In this regard, the VA examiner in April 2013 opined that it was less likely than not that the Veteran's current left wrist disability, carpal tunnel syndrome, was incurred in service, or was secondary or aggravated by any service-connected disability. While the examiner noted the Veteran's report of periodic episodes of left hand/finger numbness triggered by certain activities since service, the service treatment records failed to show any findings consistent with his current left wrist carpal tunnel syndrome. Moreover, the disorder was not diagnosed until many years after service and pursuant to the Veteran's report, was more symptomatic during his employment from 2005 to 2012, which involved a great deal of repetitive movements with both wrists. The examiner further noted the Veteran indicated that the symptoms decreased in severity once he was no longer employed with that employer, consistent with a finding that the disorder was not service related. There is no competent medical opinion to the contrary. The Board recognizes the Veteran's contentions as to the diagnosis of a left wrist disability and relationship between his current condition and left wrist tendonitis in service with recurrence of symptoms. The Board acknowledges that the Veteran is competent to report about what he experienced; however, as to the specific issue in this case, the diagnosis of carpal tunnel syndrome, and its etiology are not subject to lay observation or assertion, and fall outside the realm of common knowledge of a lay person. The diagnosis is based on clinical findings, to include neurological studies and is medical in nature. Due to the medical complexity of the issues involved, the Veteran's assertions alone are insufficient to establish service connection. As a lay person, the Veteran has not been shown to be qualified through education, training, and expertise to offer an opinion on a medical diagnosis or on medical causation. Thus, his lay assertions are of little, if any, probative value when offered to establish a causal connection between his lumbar spine disability and service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Moreover, whether the symptoms the Veteran reportedly experienced in service or following service are in any way related to his current left wrist carpal tunnel syndrome is also a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the onset and etiology of his current left wrist disability is not competent evidence to create the requisite nexus. For the reasons set forth above, the Board finds the opinion of the VA examiner to be the most probative on this point. In summary, the most probative evidence of record indicates that the Veteran was not shown to have a chronic left wrist disability during service or for many years thereafter. Moreover, the most probative evidence indicates he does not currently have left wrist tendonitis, and that his currently diagnosed left wrist carpal tunnel syndrome was not shown in service or for many years after service, and is not otherwise related to active service. Accordingly, the preponderance of the evidence is against the claim for service connection for a left wrist condition and the claim is denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Bilateral Hearing Loss The Veteran contends that he developed bilateral hearing loss in service. Specifically, at the October 2009 personal hearing, the Veteran related onset of hearing loss in service due to excessive noise exposure during the performance of his duties in the artillery field. Service connection for impaired hearing shall only be established when hearing status, as determined by audiometric testing, meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels), over a range of frequencies (in Hertz ). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a Veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385 (2013). For the purposes of applying the law administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 (2013). Audiological testing in service showed marked fluctuations in hearing. For instance, audiograms conducted in April 1996, May 1996, January 1997, November 1997, December 2001, January 2002, January 2003, December 2003, and July 2004, showed that the Veteran exhibited bilateral hearing loss for VA purposes, under 38 C.F.R. § 3.385; in December 1997, left ear hearing loss, but not right ear hearing loss, was shown, and; audiograms in August 1993, April 1995, July 1996, November 1997, November 1998, March 1999, March 2001, and November 2001, showed that he did not meet VA's criteria for hearing loss disability in either ear. On audiology referral in January 2002, the clinician noted a great deal of noise exposure in the military. He was diagnosed with mild to moderate sensorineural hearing loss. He was determined to be a candidate for hearing amplification. The Veteran was cleared for hearing aids in March 2004. On VA examination in April 2013, the results of puretone thresholds, in decibels, at 500, 1000, 2000, 3000, and 4000 Hertz on the right were 20, 20, 20, 15, and 20, and on the left were 20, 20, 20, 25 and 25. His speech recognition score was 94 percent, bilaterally. The examiner diagnosed normal hearing in the right ear and left ear sensorineural hearing loss in the higher frequencies 6000 Hertz or higher. The examiner opined it was less likely than not that the claimed hearing loss was incurred in service because the Veteran did not have hearing loss in either ear pursuant for VA purposes. The April 2013 VA audiological examination does not show hearing loss pursuant to 38 C.F.R. § 3.385. The Veteran is competent to describe symptoms of hearing loss, which he can perceive, but hearing loss for the purpose of VA disability compensation is not a condition capable of lay observation because it relies upon audiometric, i.e., diagnostic, testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Although the Veteran is competent to describe symptoms of hearing loss, the diagnosis and causation require the application of medical expertise to the facts presented, which include the Veteran's history and symptomatology and audiology testing as required. 38 C.F.R. § 3.385 (2013). Therefore, the Board determines that hearing loss disability under 38 C.F.R. § 3.385 for VA compensation is not a simple medical condition that a lay person is competent to identify as a lay person is not qualified through education, training, or experience to interpret audiology testing, and the Board determines that hearing loss is not a simple medical condition. In this case, there is no competent evidence of hearing loss in either ear for VA purposes at anytime during the period on appeal. The relevant question at issue is whether the Veteran has a hearing disability at present, as defined by 38 C.F.R. § 3.385, so as to meet the criteria for service connection for defective hearing. The Veteran was examined by VA and the diagnostic findings from the audiological examination in April 2013 failed to show hearing loss for VA compensation purposes, and there is no competent medical evidence showing that he meets the criteria for a diagnosis of hearing loss for VA purposes at any time during this appeal. 38 C.F.R. § 3.385; McClain v. Nicholson, 21 Vet. App. 319 (2007). Thus, the findings do not satisfy the criteria for bilateral hearing loss for VA purposes. 38 C.F.R. § 3.385. Given the lack of competent diagnostic evidence showing that he has a hearing disability in either ear at present or at any time during the period on appeal, as that term is defined in 38 C.F.R. § 3.385, service connection must be denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Residuals of Bilateral Shin Splints The Veteran reported onset of shin splints during service in 1999. He claims the condition developed secondary to the service-connected knee disabilities. Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2013). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2013); Allen v. Brown, 7 Vet. App. 439 (1995). The service treatment records do not show residuals of shin splints disability. On VA examination in April 2013, the Veteran reported a history of shin splints with running. He denied any recurrence of symptoms within the past 5 years. While the examiner acknowledged the Veteran's reported history of shin splints, following a review of the claims file and an examination of the Veteran's lower extremities, the examiner found that the Veteran did not currently suffer from residuals of shin splints in either extremity. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, residuals of bilateral shin splints, falls outside the realm of common knowledge of a lay person. In this regard, while the Veteran can competently report the onset and symptoms of pain, any actual diagnosis of residuals of bilateral shin splints requires objective testing to diagnose, and can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, whether symptoms the Veteran experienced in service or following service are in any way related to any current service-connected knee disabilities requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). To the extent that the Veteran himself believes that he has current residuals of shin splints that are due to service or his service-connected knee disorders, as a lay person, he is not shown to possess any specialized training in the medical field. The Veteran's opinion as to the etiology of his claimed residuals of shin splints is not competent medical evidence, as such question requires medical expertise to determine. Id. In any event, the Board concludes that the medical evidence, which reveals no findings of residuals of shin splints, is of greater probative value than the lay contentions of the Veteran. The Board has also considered the holding in McClain v. Nicholson, 21 Vet. App. 319 (2007). At no time during the period on appeal did the Veteran receive a residuals of bilateral shin splints diagnosis. Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C.A. §§ 1110; 1131. In the absence of proof of present a disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997) (38 U.S.C.A. § 1131 requires existence of present disability for VA compensation purposes); see also Wamhoff v. Brown, 8 Vet. App. 517, 521 (1996). In reaching these conclusions, the Board notes that, under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be given to the claimant in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim in this case, and that doctrine is not applicable. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a psychiatric disorder, depression and obsessive compulsive disorder, is denied. Service connection for a left wrist disorder is denied. Service connection for hearing loss is denied. Service connection for the residuals of shin splints is denied. REMAND The Veteran claims that he is entitled to service connection for left elbow strain. At the October 2009 personal hearing, the Veteran reported onset of left elbow symptoms during service, associated with repeated heavy lifting in the artillery field, as well as left elbow strain. In a December 2001 report of medical history, the Veteran reported elbow stiffness and pain associated with push-ups and weight lifting. The Veteran underwent a joints examination in February 2002. He related onset of bilateral elbow pain in 2001. He denied a specific injury. On examination, the examiner noted tenderness in the lateral epicodyle area with normal range of motion. The examiner noted elbow strain disorder pending x-rays and possible lateral epicondylitis, however, x-rays of the elbow revealed no abnormalities. On general medical examination in February 2002, the Veteran complained of popping in the elbows and limitations lifting more than 25 pounds. A report of medical history in January 2003 noted the Veteran's report of bursitis of the elbows in 2002. Pursuant to the November 2012 remand, the Veteran was to be scheduled for a VA examination to determine the nature and etiology of the Veteran's left elbow complaints. The Veteran was afforded a VA examination in April 2013. The examiner concluded that the Veteran did not have a left forearm or elbow condition based on the Veteran's denial of symptoms at that time. However, no objective clinical findings were recorded with respect to this disability. As stated in the remand instructions, the medical examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. The examiner should specifically discuss the appellant's contentions and his report of recurrence of symptoms since he was discharged from service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant's report of inservice injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Because the requested development was not completed, an additional remand is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). On remand, relevant ongoing medical records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Request the appellant to identify all medical providers (VA and private) from whom he has received left elbow treatment, and complete and return an appropriate authorization form for each treatment provider identified. After obtaining the completed release form, the RO/AMC should request all identified pertinent medical records. All development efforts should be associated with the claims file. If the requested records cannot be obtained, the Veteran should be notified of such. 2. Obtain, either electronically or physically, all relevant treatment records for treatment received at the VA Medical Center, not already in the claims file. 3. After the above development is completed, arrange for the Veteran to be examined by a VA examiner in order to determine the nature and etiology of the Veteran's left elbow complaints. All indicated tests should be accomplished. The examiner should review the claims folder and should note that review in the report. The examiner should address the following: a) Identify any current left elbow disability present. b) Is it at least as likely as not (50 percent or greater probability) that any left elbow disability found on examination is etiologically related to related to service, to include in-service findings of left elbow strain and bursitis? The examiner must consider lay statements regarding in-service and post-service symptomatology. Dalton v. Nicholson, 21 Vet. App. 23 (2007). c) Is it at least as likely as not (50 percent or greater probability) that any left elbow disability was caused by a service-connected disability? d) Is it at least as likely as not (50 percent or greater probability) that any left elbow disability was aggravated (permanently increased in severity beyond the natural progress of the condition) by a service-connected disability? If aggravation is found, the examiner should provide the baseline manifestations of the Veteran's left elbow disability found prior to aggravation and the increased manifestations which, in the examiner's opinion, are proximately due to a service-connected disability. The examiner must provide complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the provided conclusions. 4. After the development requested above as well as any additional development deemed necessary has been completed, the record should again be reviewed. If the benefits sought on appeal remain denied, then the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs